Every finding on record at Bayside Wellness, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that all of the Hospice Interdisciplinary Group completed an initial comprehensive assessment within the required 5 days following election of the hospice benefit. CLINICAL RECORD 3: The patient elected the hospice benefit on 01/15/2025. Review of the clinical record indicated that on 01/16/2025, the social worker contacted the family to introduce herself and arrange the initial comprehensive assessment. The coordination notes dated 01/25/2025, documented that a voicemail was left requesting a return call to schedule the visit. The initial comprehensive assessment was subsequently completed on 01/31/2026. No additional documentation was found regarding follow-up attempts between the initial outreach and the completion of the assessment. During a joint record review and interview conducted on 01/28/2026, the Administrator (Personnel Record 1) and Director of Nursing (Personnel Record 2) acknowledged that the assessment had not been completed within the required five-day timeframe and that the social worker did not conduct appropriate follow-up after the initial contact.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by interview and personnel record review. In 2 of 9 (22%) personnel records reviewed it was revealed that the agency did not ensure that licensed professionals participated in the hospice required in-service training. PERSONNEL RECORD 3: Review of the personnel record for the registered nurse case manager hired on 10/17/2022 revealed that there was no documentation confirming completion of the required annual in-service trainings for 2023, 2024, and 2025. PERSONNEL RECORD 5: Review of the personnel record for the chaplain hired on 06/27/2022, revealed that there was no documentation confirming completion of the required annual in-service trainings for 2023, 2024, and 2025. Although some in-service records were present, the agency maintains a mandatory annual in-service schedule, and the personnel records did not contain evidence that the chaplain completed all required trainings as assigned. DOCUMENT 5: (Agency Name) In-Service Record (Annual In-Services) HIPPA, Infection Control/Bloodborne Pathogens/Standard Precautions, Safety/Emergency Management, Boundaries with Patient/Family/Caregiver, Abuse and Neglect, Patient Rights, Grievance Reporting, Ethical Concerns, Cultural Diversity, Special Communication Needs, Pain and Symptom Control/Physiological Aspects of Care, Medical Emergency Procedures and Patient Death, Hospice Philosophy, goals/services, Advance Directives, POA, On-Call process, IDT Approach to Care, Psychosocial and spiritual aspects to terminal care, Family dynamics and crisis management, Bereavement Care During a joint record review and interview conducted on 01/29/2026, the Director of Nursing (Personnel Record 2) acknowledged that documentation of the required in-service training was not present in the personnel files. She explained that the agency’s process was to assign in-service education throughout the year, with staff expected to sign a form upon completion of each course. The signed forms are then placed in the personnel files. She further stated that the agency does not have an effective system in place for tracking completion of these in-services.

It is required that if no State licensing laws, certification or registration requirements exist for the profession, the following personnel qualification requirements must be met. A registered nurse (RN) is a graduate of a school of professional nursing and is currently licensed, certified, or registered in the state(s) in which they practice. This standard was not met as evidenced by interview and personnel record review. In 2 of 2 (100%) registered nurse personnel records reviewed revealed that the agency did not ensure verification of current nursing licenses. PERSONNEL RECORD 2: Review of the personnel record for a registered nurse hired on 10/17/2022, revealed that although the RN’s license was verified at the time of hire, the subsequent licenses with expiration dates of 03/12/2025, and 03/12/2027, were not verified. The personnel file contained only copies of the RN’s licenses without documentation of verification. PERSONNEL RECORD 3: Review of the personnel record for a registered nurse hired on 8/26/2024, revealed that although the RN’s license was verified at the time of hire, the subsequent licenses with expiration date of 07/25/2027 was not verified. The personnel file contained only a copy of the RN’s license without documentation of verification. During a joint record review and interview conducted on 01/29/2026, with the Director of Clinical Services (Personnel Record 2) and the Administrator (Personnel Record 1), both leaders acknowledged that their established practice has been to verify nursing licenses only at the time of hire and thereafter rely solely on obtaining copies of renewed licenses, rather than performing ongoing verification.